Disclaimer

The App is based on the AAD psoriasis clinical guidelines. Adherence to the guidelines recommendations will not ensure successful treatment in every situation. Furthermore, these guidelines should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the disease. This guideline reflects the best available data at the time the guideline was prepared. The results of future studies may require revisions to the recommendations in this guideline to reflect new data.

Clinical Decision Tree

1Patients with non-deforming psoriatic arthritis without any radiographic changes, loss of range of motion, or
interference with tasks of daily living should not automatically be treated with tumor necrosis factor (TNF) inhibitors.
It would be reasonable to treat these patients with a non-steroidal anti-inflammatory agent or to consult a rheumatologist
for therapeutic options.

2Patients with limited skin disease should not automatically be treated with systemic treatment if they do not
improve, because treatment with systemic therapy may carry more risk than the disease itself.

Systemic - hypothalamic-pituitary-adrenal axis suppression may occur with use of medium and high potency topical steroids. Unilateral or bilateral avascular necrosis of the femoral head rarely occurs.

Increased intraocular pressure, glaucoma and cataracts have been reported with use around the eye.

Risks increase when used with excessive frequency or duration.

It is unknown if there is an increased risk of infection with chronic use.

Baseline Monitoring:

None

Ongoing Monitoring:

Assessment of growth in children using for long term

Regular skin checks for all patients on long term therapy to assess for atrophy

Pregnancy:

Category C

Nursing:

Unknown safety.

Pediatric Use:

Because of the increased skin surface/body mass ratio, the risks to infants and children may be higher for systemic effects
secondary to enhanced absorption. Growth retardation is also a potential concern.

Vitamin D Analogues

Vitamin D Analogues

Indication:

Plaque type psoriasis

Dosing:

Twice daily to affected areas

Efficacy:

In two large studies of plaque type psoriasis of the body, 70-74% of patients treated with calcitriol or calcipotriene ointment
showed either 75% improvement or marked improvement to clearing as compared with 18-19% of patients treated with placebo.
60% of scalp psoriasis patients treated with calcipotriene solution showed clearance or marked improvement as compared to
17% of placebo patients.

Combination of calcipotriene and betamethasone ointment – In a 4 week trial of patients with mild to severe plaque psoriasis
- 48% of patients treated with the combination agent achieved absent or mild psoriasis, compared to 16.5% of patients treated
with calcipotriene once daily, 26.3% of patients treated with betamethasone once daily, and 7.6% of patients treated with
placebo. A 52 week clinical practice usage study showed 70-80% of patients achieving clear or almost clear status with no
drug-related serious adverse events such as HPA axis oppression or stria when used on an as needed basis.

Use in combination with topical corticosteroids gives added benefit.

Contraindications/Adverse Reactions:

Irritation in lesional and peri-lesional skin that is transient.

Reversible elevation of serum calcium – more likely to occur in patients treated with greater than 100 g/week.

Causes photosensitivity, but no contraindications to combining with UVB phototherapy

When using combination calcipotriene/betametasone, the side effects of high potency topical corticosteroids including HPA
axis suppression, skin atrophy, among others (see above) may occasionally occur.

Pregnancy and nursing:

Category C

No information on excretion in breast milk and pregnant and nursing mothers were excluded from clinical studies.

Tazarotene

Tazarotene

50% or more improvement, seen in 63% and 50% of patients treated with tazarotene 0.1% gel and 0.05% gel used once daily
for 12 weeks, compared to 31% of patients treated with vehicle.

Overall lesional assessment of none,minimal or mild found in 40 – 51% of patients treated with tazarotene 0.1% cream and
0.05% cream used once daily for 12 weeks, compared to 25% of patients treated with vehicle.

Best used in combination with topical corticosteroids

Contraindications/Adverse Reactions:

Most common side effect is skin irritation in lesional and perilesional skin.

Photosensitizing

Pregnancy and nursing:

Pregnancy category X

Excreted in mammalian milk, but quantity in human milk is unclear.

Pediatric use:

No available data in psoriasis patients under age 18; for acne, approved to age 12.

Tacrolimus and Pimecrolimus

Tacrolimus and Pimecrolimus

No FDA approved indications for psoriasis. Primary indications for off label use are for facial and intertriginous psoriasis.

Dosing:

Applied twice daily to affected areas. No length of course is specified.

Efficacy:

Plaque psoriasis – not generally effective

Intertriginous and facial psoriasis: 65% of patients treated with tacrolimus 0.1% ointment were clear or almost clear after
8 weeks of therapy compared with 31% of patients treated with placebo. 71% of the patients treated with pimecrolimus 0.1%
cream were clear or almost clear after 8 weeks of therapy as compared to 21% of patients treated with placebo.

Contraindications/Adverse reactions:

There are no specific contraindications/adverse reactions for psoriasis.

Most common side effect for both medications is burning and itching.

A controversial lymphoma “black box” warning has been issued by the FDA

Pregnancy and nursing:

Category C

Tacrolimus and pimecrolimus are found in human milk and are not recommended for nursing mothers.

Pediatric use:

Topical tacrolimus (0.03%) and topical pimecrolimus are approved for patients age 2 years or older for atopic dermatitis.

Do not combine with other salicylate drugs. Systemic absorption although rare, can occur especially when applied to over
20% of body surface or in patients with abnormal hepatic or renal function. Salicylic acid decreases the efficacy of UVB
phototherapy due to a filtering effect and should not be used before UVB phototherapy

Pregnancy/nursing:

Appears to be a safe choice for the control of localized psoriasis in pregnancy

Pediatric use:

Due to greater risk of systemic absorption and toxicity, salicylic acid should be avoided in children

Coal Tar

Coal Tar

Indications:

Used in the treatment of psoriasis for over 100 years. Although the use of tar products for treatment of localized psoriasis
has decreased over time in the US, they are still often used in other countries

Coal tar is carcinogenic in animals, but in humans there are no convincing data proving carcinogenicity and epidemiologic
studies fail to show increased risk of skin cancer in patients who use coal tar.

Pregnancy and nursing:

Risk of topical coal tar used for short periods of time during pregnancy is likely to be small

For those without risk factors, consider liver biopsy in patients with cumulative doses of more than 3.5-4g methotrexate.

For patients without risk factors, consider repeat liver biopsies after each subsequent 1.5g dosage, based on LFT’s, risk
factors such as diabetes and obesity, or in consultation with a hepatologist.

The aminoterminal peptide of procollagen III is used in Europe (but is generally not available in the United States) as
a test for hepatic fibrosis, reducing the need for frequent liver biopsies.

Pregnancy:

Category X

Males and females considering conception should be off methotrexate for 3 months prior to attempting to conceive. Should
pregnancy ensue prior to this time period, consider genetic counseling

Nursing:

Mothers receiving methotrexate should not breast feed.

Pediatric Use:

Methotrexate is approved for the treatment of juvenile rheumatoid arthritis.

Low dose methotrexate has been used effectively and safely in children for a variety of dermatologic and rheumatologic disorders.

Psoriatic Arthritis:

Although there are only two small controlled trials evaluating methotrexate for psoriatic arthritis that are inadequately
powered to assess clinical benefit, methotrexate is often used as the primary agent to treat psoriatic arthritis.

Cyclosporine

Cyclosporine

Indication:

Adult, non-immunocompromised patients with severe, recalcitrant psoriasis (Severe is defined by the FDA as extensive or
disabling plaque psoriasis; Recalcitrant is defined by the FDA as those patients who have failed to respond to at least
one systemic therapy or in patients for whom other systemic therapies are contraindicated, or cannot be tolerated)

Some guidelines suggest use of cyclosporine in moderate to severe psoriasis

Transplant recipients as young as 1 year old have been treated with no unusual adverse events. While safety and efficacy
of cyclosporine for children < 18 yrs with psoriasis has not been established, it may be considered in this patient population
with severe psoriasis.

Psoriatic Arthritis:

There are studies demonstrating the efficacy of cyclosporine for psoriatic arthritis

Acitretin

Acitretin

Lower doses (25 mg/day or less) often used to minimize side effects, especially in combination regimens

When acitretin is added to UV, light dose should be reduced by 30-50%

Short-term Results:

Efficacy rates not well defined but are high, based on studies of high dosages that are poorly tolerated

Efficacy rates when used in combination with phototherapy are higher

Long-term Results:

Not reported

Contraindications:

Acitretin is a potent teratogen and must be avoided in women of child-bearing potential

Severely impaired liver or kidney function

Chronic abnormally elevated blood lipid values

Toxicity:

Cheilitis

Alopecia

Xerosis, pruritus

Xerophthalmia, night blindness

Dry mouth

Paronychia

Paresthesias

Headache, pseudotumor cerebri

Nausea, abdominal pain

Joint pain

Myalgia

Hypertriglyceridemia

Abnormal LFT’s

Drug Interactions:

Etretinate can be formed with concurrent ingestion of acitretin and ethanol

Acitretin may potentiate glucose lowering effect of glibenclamide

May interfere with the contraceptive effect of microdosed progestin minipill

Acitretin and methotrexate can both cause hepatotoxicity, therefore they should be combined with caution.

Acitretin may reduce the protein binding of phenytoin

Acitretin and tetracyclines can both increase intracranial pressure. Their combined use should be avoided.

Concomitant administration of vitamin A and other oral retinoids with acitretin should be avoided

Baseline Monitoring:

History and Physical Examination

Lipid profile, CBC, LFT’s, renal function tests

Pregnancy test if indicated

Ongoing Monitoring:

LFTs, lipid profile at 2 wk intervals for the first 8 weeks, then every 6-12 wks

CBC, renal function tests every 3 months

Pregnancy test if indicated

Pregnancy:

Category X

Nursing:

Mothers receiving acitretin should not breast-feed.

Pediatric Use:

The safety and efficacy of acitretin in children with psoriasis is not established. High dose, long term oral retinoid use
has been associated with ossification of interosseous ligaments and tendons of the extremities, skeletal hyperostoses, decreases
in bone mineral density, and premature epiphyseal closure.

Azathioprine

Azathioprine

Thiopurine methyl transferase levels are generally used to guide dosing

One suggested daily schedule guided by results of TPMT values

TPMT <5.0 U

do not use azathioprine

TPMT 5 -13.7 U

0.5mg/kg max dose

TPMT 13.7 - 19.0 U

1.5mg/kg max dose

TPMT >19.0 U

2.5mg/kg max dose

Alternatively, start at 0.5mg/kg, and monitor for cytopenia. If no cytopenia, can increase dose by 0.5 mg/kg/day after 6-8 wks if necessary and increase by 0.5 mg/kg/day every 4 wks thereafter as needed.
Generally dosed at 75 – 150 mg/day

Efficacy:

In one study 19/29 pts had >75% improvement but in another smaller study 5/10 pts had >25% improvement

Hydroxyurea

Hydroxyurea

Initial dose of 500 mg PO BID increasing to up to 3 g/day as tolerated.

Weekly dose of 3 - 4.5 g/week has also been utilized

Short-term Results:

Efficacy rates vary widely

One study showed that 55% of 31 patients had at least a 70% reduction in PASI score (mean treatment time of 36 weeks), while
another study comparing hydroxyurea to methotrexate showed a 48% reduction in PASI score after 12 weeks of hydroxyurea.

Long-term Results:

One study found that 60% of 85 pts treated for a mean of 16 months had a complete or almost complete clearance

Leflunomide

Leflunomide

In the only randomized controlled trial of 190 pts, 24 wks of leflunomide dosed as above, led to a PASI 75 of 17% vs placebo
response of 8% (p =.048)

Long-term Results:

Not reported

Contraindications:

Patients with hypersensitivity to leflunomide or its metabolites

Toxicity:

Most common side effects include nausea, diarrhea, loss of appetite, weight loss, headache, dizziness

Less frequent adverse reactions may include severe liver injury, including fatal outcome. Most cases of severe liver injury
occur within 6 months of therapy and in pts with multiple risk factors for hepatotoxicity.

Rare reports of pancytopenia, agranulocytosis and thrombocytopenia in patients receiving leflunomide. This occurs in patients
who have been treated with methotrexate or other immunosuppressive agents, or who had recently discontinued these.

Drug Interactions:

Co-administration of leflunomide with methotrexate demonstrates no pharmacokinetic interaction between the two drugs but
can lead to an increased risk of hepatotoxicity.

When leflunomide is given with rifampin, leflunomide levels are increased

Baseline Monitoring:

History and Physical Examination

CBC/diff and LFT’s.

Pregnancy test if indicated

Ongoing Monitoring:

Monthly complete blood count with differential and liver function tests for the first six months and then every 6 – 8 weeks

Pregnancy testing if indicated

Pregnancy:

Category X

Nursing:

Leflunomide should not be used by nursing mothers.

Pediatric Use:

No data

Psoriatic Arthritis:

In the only randomized controlled study of 190 pts with psoriasis and psoriatic arthritis, 59% of pts treated with leflunomide
vs 30% of placebo pts were responders by the PsARC

Tacrolimus

Tacrolimus

Indication:

There is no FDA approved use for psoriasis

Dosing for Psoriasis:

0.05 – 0.15 mg/kg

Duration of Dosing:

Unknown

Short-term Results:

Efficacy rates are poorly characterized. Pts dosed at 0.05 mg/kg showed no difference from placebo at 3 wks. When dosed
at 0.10 – 0.15 mg/kg, by 9 wks there was a statistically significant improvement in PASI compared to placebo

Long-term Results:

Not reported

Contraindications:

Patients with hypersensitivity to tacrolimus or its metabolites.

Side effects (profile similar to cyclosporine):

Most common side effects include tremor, headache, nausea, diarrhea, hypertension and abnormal renal function tests

6-Thioguanine

6-Thioguanine

Indication:

There is no FDA approved use for psoriasis

Dosing:

Start at 80 mg two times per week. Increase by 20 mg every 2-4 weeks. Maximum dose is 160 mg 3 times per week.

Short-term Results:

Open label trial of 14 pts treated with pulse dosing followed by maintenance dosage (120 mg twice a week to 160 mg three
times per week). Of 11 pts who became longer term responders, 6/11 showed a response after 2-4 weeks

Long-term Results

76 patients followed for over one month. At 24 months, 58% were effectively maintained.

Biologics for Psoriasis

Alefacept

Alefacept

15 mg every week given as an intramuscular injection for 12 weeks, with a 12 week follow-up non-treatment period

Short Term Results:

21% of patients achieved a PASI 75 at week 14

Long Term Results:

Associated with long remissions in a subset of responders.

Prior response to alefacept is a likely marker of future treatment response. Thus, patients responding to the first course of therapy may be treated long-term with repeated 12-week courses of alefacept – at a minimum of 24 week intervals.

TNF Inhibitors

General Recommendations

General Recommendations

Anti-TNF agents are contraindicated in patients with active, serious infections.

Tuberculosis testing (PPD) should be performed on all patients who will be treated with TNF inhibitors as there are reports of tuberculosis reactivation in patients treated with this class of drug.

Do not use with live vaccines; biologically inactive or recombinant vaccines may be considered, although the immune response of these vaccines could be compromised.

Since there is an association between anti-TNF therapy and demyelinating diseases {i.e. multiple sclerosis (MS)} TNF inhibitors should not be used in patients with MS or other demyelinating diseases. First degree relatives of patients with MS have an increased risk of developing MS, with a sibling relative risk of between 18 and 36, evidence strongly suggesting that TNF inhibitors should not be used in first degree relatives of patients with MS.

Since there have been reports of new onset and worsening of congestive heart failure (CHF) in patients treated with TNF inhibitors, caution should be used when considering TNF inhibitor use in patients with CHF. It is recommended that patients with New York Heart Association Class 3 or 4 CHF avoid all use of TNF inhibitors and patients with Class 1 or 2 CHF undergo echocardiogram testing. If the ejection fraction of these patients is less than 50%, then TNF inhibitor treatment should potentially be avoided.

Hepatitis B reactivation following treatment with TNF inhibitors has been reported. In the appropriate clinical setting, patients should be screened for hepatitis B infection.

Although there are rare reports of drug-induced reversible side effects including lupus without CNS or renal complications, cytopenias, multiple sclerosis, and exacerbation as well as new onset congestive heart failure with the other three TNF inhibitors, there have been no reports of these reactions with golimumab to date. However, golimumab is a TNF inhibitor and it should be used cautiously.

Baseline Monitoring:

PPD is required

LFT and CBC

Ongoing Monitoring:

Periodic history and physical examination recommended while on treatment.

Infliximab

5mg/kg given intravenously at weeks 0, 2, 6 and then every 6 - 8 weeks. Dose and interval of infusions may be adjusted as needed.

Response:

ACR 20 at week 14 is 58%

Toxicities:

Infusion reactions and serum sickness can occur - more commonly in patients who have developed antibodies.

The incidence of infusion reactions may be reduced by concurrent administration of methotrexate.

Rare cases of serious infections (i.e., tuberculosis) and malignancies including hepatosplenic T-cell lymphoma (in children). There are rare reports of drug-induced, reversible side effects including lupus without renal or CNS complications, cytopenias, MS as well as exacerbation of and new onset of CHF.

Baseline Monitoring:

PPD is required.

LFT’s, CBC, and hepatitis profile.

Ongoing Monitoring:

Periodic history and physical exam are recommended while on treatment.

RISK FACTORS FOR HEMATOLOGIC TOXICITY FROM METHOTREXATE

RISK FACTORS FOR HEPATOTOXICITY FROM METHOTREXATE

History of or current greater than moderate alcohol consumption (methotrexate toxicity is associated with a history of total lifetime alcohol intake before methotrexate therapy. The exact amount of alcohol that leads to risk is unknown and differs from person to person.)

Persistent abnormal liver chemistry studies

History of liver disease including chronic hepatitis B or C

Family history of inheritable liver disease

Diabetes mellitus

Obesity

History of significant exposure to hepatotoxic drugs or chemicals

Hyperlipidemia

MONITORING FOR HEPATOTOXICITY IN PATIENTS WITH NO RISK FACTORS FOR HEPATOTOXICITY

No baseline liver biopsy

Monitor liver function tests monthly for the first 6 months and then every 1-3 months thereafter

For elevations < two fold upper limit of normal — repeat in 2-4 weeks

For elevations > two fold but < three fold upper limit of normal — closely monitor, repeat in 2-4 weeks, and decrease dose as needed

For persistent elevations in 5/9 AST levels over a 12-month period or if there is a decline in the serum albumin below the normal range with normal nutritional status, in a patient with well-controlled disease, a liver biopsy should be performed

Consider liver biopsy after 3.5 - 4.0 g total cumulative dosage
or

Consider switching to another agent or discontinuing therapy after 3.5 - 4.0 g total cumulative dosage
or

Consider continuing to follow according to above guidelines without biopsy

MONITORING FOR HEPATOTOXICITY IN PATIENTS WITH RISK FACTORS FOR HEPATOTOXICITY

RELATIVE CONTRAINDICATIONS FOR THE USE OF METHOTREXATE

Abnormalities in renal function may require a marked reduction in the dose as 85% of methotrexate is renally excreted

Abnormalities in liver function – LFT’s should be followed and all elevations require careful monitoring

Hepatitis, active or recurrent

Greater than moderate alcohol consumption – While there is little data to support specific limits on alcohol consumption, some physicians require patients to completely refrain from alcohol while others allow daily alcohol intake. A history of alcoholism is particularly worrisome if there is baseline liver damage

Concomitant use of hepatotoxic drugs – more frequent monitoring of liver function tests should be considered

Active infectious disease, particularly chronic infections that are likely to be worsened by immunosuppressive effects of methotrexate such as active untreated tuberculosis or acquired immunodeficiency syndrome. Methotrexate should be withheld during acute infections

Current use of other immunosuppressive agents

Conception should be avoided during methotrexate treatment and afterwards for at least three months in the male and three ovulatory cycles in women

Since there is a broad range of MED for NB-UVB by skin type, MED testing is generally recommended.

It is critically important to meter the UVB machine once weekly. UVB lamps steadily lose power. If the UV output is not periodically measured and the actual output calibrated into the machine, the clinician may have the false impression that the patient can be treated with higher doses when the machine is actually delivering a much lower dose than the number entered.

According to Minimal Erythema Dose

Administered 3 times a week

Initial UVB

50% of the MED

Treatment 1 -20

Increase by 10% of the initial MED

Treatment 21 and after

Increase as ordered by physician

If subsequent treatments are missed for:

4-7 days

Keep dose same

1-2 weeks

Decrease the dose by 25%

2-3 weeks

Decrease the dose by 50% or start over

3-4 weeks

Start over

Maintenance Therapy for NB-UVB after >95% clearance

1x/week

NB-UVB for 4 weeks

Keep the dose the same

1x/2 weeks

NB-UVB for 4 weeks

Decrease dose by 25%

1x/4 weeks

NB-UVB

50 % of highest dose

The minimum frequency of phototherapy sessions required per week for successful maintenance as well as the length of maintenance period varies tremendously between individuals. The above table represents the most ideal situation where the patient can taper off phototherapy. In reality, many patients require once a week NB-UVB phototherapy indefinitely for successful long term maintenance.

References

Adapted with permission from Do A, Koo J. Initiating narrow-band UVB for the treatment of psoriasis: how to do MED skin testing. Psoriasis Forum 2004;10:7-11.

CPT Coding for Psoriasis Treatment/Procedures

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours
of care under direct supervision of the physician (includes application of medication and dressings)

96920

Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

Laser treatment for inflammatory skin disease (psoriasis); total area over 500 sq cm

96999

Unlisted special dermatological service or procedure

HCPCS Codes for Psoriasis Treatment

Adalimumab

J0135

Alefacept

J0215

Etanercept

J1438

Golimumab

J3590*

Infliximab

J1745

Ustekinumab

J3357

* To identify this drug to an insurance company, a practice must enter the name of the drug, strength, dose given, and
National Drug code (NDC) found on the vial in the information section (item 19) of the CMS1500 claim form.

Psoriasis Treatment Reimbursement Algorithm

The key to effective billing and consistent reimbursement of dermatology services is a thorough understanding of the required
coding system and documentation guidelines.

CODING
Health information coding is defined as: "the transformation of verbal descriptions of diseases, injuries, and procedures
into numeric or alphanumeric designations."

ICD-9-CM
ICD-9-CM is the tool to use to find the most accurate diagnosis codes that establish medical necessity for the procedures
performed in the dermatology practice. Dermatology procedures are coded using CPT codes.

CPT
CPT also includes guidelines and principles for the correct application of CPT procedural codes. Understanding the guidelines
for the correct application of CPT as well as knowing how to properly use modifiers, will create a clean claim that bypasses
software edits on its first submission, ensuring the claim’s prompt payment.

HCPCS
HCPCS is a system for identifying items and services. It is not a methodology or system for making coverage or payment determinations
and the existence of a code does not, of itself, determine coverage or noncoverage for an item or service.

DISCLAIMER
This is a conceptual scheme based on the recommendations of a guideline. A third party payer may have separate or additional
requirements. American Academy of Dermatology has provided this information to the best of its knowledge as a guide to providers.
AAD does not guarantee reimbursement. Providers assume responsibility for all care provided and claims filed. For additional
information please call 866-503-SKIN (7546).

Moll and Wright Criteria for Psoriatic Arthritis

Polyarticular, symmetric arthritis (RA-like)

Oligoarticular (less than 5 joints), asymmetric arthritis

Distal interphalangeal joint predominant

Spondylitis predominant

Arthritis mutilans

* To meet the Moll and Wright 1973 classification criteria for psoriatic arthritis, a patient with psoriasis and inflammatory
arthritis who is seronegative for RA must present with 1 of the above 5 clinical subtypes. Moll and Wright specificity is
98% and sensitivity is 91%.

CASPAR Criteria for the Diagnosis of Psoriatic Arthritis

The CASPAR (classification criteria for psoriatic arthritis) criteria consist of established inflammatory articular disease*
with at least 3 points from the following features:

Current psoriasis (assigned a score of 2; all other features are assigned a score of 1)

A personal history of psoriasis (unless current psoriasis is present)

A family history of psoriasis (unless current psoriasis is present or there is a personal history of psoriasis)

Current dactylitis or history of dactylitis recorded by a rheumatologist

ACR50 and ACR70 analysis include the same criteria as ACR20, with the use of a higher percentage improvement (50% and 70%).

Sharp Scoring

EROSIONS

Hands
Second through fifth DIP joints
All five metacarpophalangeal joints
The interphalangeal (IP) joint of the thumb
Wrist bones including first metacarpal base, the multangulars, the navicular, the lunate, the triquetrum and pisiform, the
radius, and the ulna.

Feet
All five metatarsal joints
Interphalangeal joint of the great toe

JOINT SPACE NARROWING

Hands
Second through fifth DIP joints
All five metacarpophalangeal joints
Wrist bones including 4th 5th and 6th carpometacarpal joints, the multangular-navicular, capitate-navicular, capitate-lunate,
and radiocarpal joints

Case Studies and Treatment Algorithms

Treatment Algorithms

Treatment of Patients with Limited Disease

*Note the use of more potent topical corticosteroids must be limited to the short term i.e. <4 weeks, with gradual weaning to 1-2 times a week usage once adequate control is obtained, and the introduction of a secondary agent, e.g. vitamin D3 preparations should be used for long term safe control

PUVA Photochemotherapy

PUVA Photochemotherapy

34-year-old Asian-American man with 2 year history of generalized plaque type psoriasis involving 30% BSA and including the palms and soles

Previous treatments include multiple topical medications with little improvement, a three month course of aggressively dosed NB-UVB phototherapy with only moderate improvement, and PUVA three times per week for 8 weeks with excellent improvement of his psoriasis with the exception of recalcitrant lesions on the palmar and plantar surfaces

Hand and foot PUVA using "soak" PUVA was employed in conjunction with oral PUVA therapy and the patient experienced almost complete clearing of his psoriasis after 12 weeks

Over the ensuing 3-4 months, the frequency of PUVA therapy was gradually decreased. Thereafter, monthly treatment with PUVA maintained almost complete clearing over a seven year period without the development of any skin cancers, although he did develop multiple PUVA lentigines.

Palmoplantar Psoriasis

Palmoplantar Psoriasis

66-year-old male with a 15-year history of psoriasis involving the face, scalp, genitalia and groin, with significant involvement of the palms and soles

The patient’s scalp psoriasis is well-controlled using topical clobetasol solution applied twice daily on the weekends

The face and suprapubic area psoriasis have responded well to tacrolimus ointment 0.1% twice daily and fluticasone ointment twice weekly as needed

His palms and soles, however, are completely refractory to treatment with multiple different potent topical corticosteroids under occlusion, calcipotriene ointment, and combination topical therapy also used under occlusion. A three month course of topical PUVA also produced only minor improvement.

This patient has is a history of depression treated with lithium, hyperlipidemia treated with atorvastatin asthma and hay fever

Physical exam reveals erythematous scaly and fissured hyperkeratotic psoriatic patches and plaques involving approximately 40% of both the palmar and plantar surfaces

The patient’s quality of life was significantly impacted with limitations in the use of his hands and significant pain with walking

Acitretin 25 mg daily was initiated. Within two months, there was substantial improvement in both the palmar and plantar psoriasis, leading to a significant improvement in this patient’s quality of life.

Reduction of his acitretin dosage to 25 mg on alternate days was then possible and the mucocutaneous side effects associated with acitretin therapy thus diminished

An attempt to reduce his lithium dose was unsuccessful due to a worsening of his depression

Recalcitrant Psoriasis and Multiple Co-Morbidities

Recalcitrant Psoriasis and Multiple Co-Morbidities

37-year-old obese woman with widespread plaque psoriasis for more than 20 years

In addition to topical steroids and vitamin D analogues, she has received more than 300 PUVA treatments and 2 years of NB-UVB with her last phototherapy treatment being 3 years previously. The NB-UVB was not effective in adequately controlling her psoriasis

Past medical history is significant for hypertension, dyslipidemia and non-insulin dependent diabetes mellitus (NIDDM), features consistent with the diagnosis of metabolic syndrome

She has had one basal cell carcinoma (BCC) and one SCC involving her trunk, excised 4 and 2 years ago, respectively

Her menstrual cycles are regular and she is sexually active but not considering pregnancy

She reports drinking one ounce of alcohol daily for the past 12 years

Current medications include metformin, rosuvastatin, fenofibrate, olmesartan and an oral contraceptive

She has mildly elevated liver enzymes thought to be due to a combination of her obesity (steatohepatitis) and her alcohol intake

On exam, she has hundreds of PUVA lentigines and several actinic keratoses involving sun exposed areas of her arms, hands and face

Thick psoriatic plaques are found on her trunk, extremities and scalp involving 35% of her BSA

There is no onychodystrophy and no signs or symptoms of psoriatic arthritis are present

A woman with generalized psoriasis: There are thick, inflammatory, scaly plaques involving 35% of her BSA

Erythrodermic Psoriasis

Erythrodermic Psoriasis

29-year-old man with a family history of psoriasis presents with a severe flare of his pre-existing psoriasis.

The patient developed plaque type psoriasis at 12 years of age, and was initially treated with low potency topical corticosteroids, but his disease became progressively worse over the subsequent 6 years with the development of extensive plaques involving his scalp, trunk, and extremities.

He was treated initially with 15 mg per week of oral methotrexate which led to significant elevations in his liver function tests after 9 months of therapy, requiring discontinuation of the methotrexate.

Subsequently, he failed to respond to a 12 week course of intramuscular alefacept, but thereafter obtained significant improvement with etanercept treatment.

Nine months prior to his presentation, he failed to renew his etanercept and approximately 7 months after his last dose of etanercept, he noticed an increased number of new psoriatic plaques.

Thereafter, an upper respiratory infection led to a rapid worsening of his psoriasis, and eventual involvement of most of his body surface area with sparing only of the palms and soles. His psoriasis was painful, and he developed frequent chills, leg swelling, and generalized arthralgias.

On physical examination, the patient was afebrile with other vital signs within normal limits. He had generalized erythematous, inflammatory patches and plaques covering 95% of his body surface area.

Superficial exfoliation of the face, palms and soles were noted, along with pitting edema of the lower extremities. Joint examination revealed swelling of the toes without any specific individual joint tenderness.

Psoriatic Arthritis

Psoriatic Arthritis

An obese, 55 year-old white male with psoriasis for 12 years with an 8 month history of painful and swollen joints in the hands, feet and knees, bilateral heel pain and morning stiffness of approximately 2 hour duration, unresponsive to non-steroidal anti-inflammatory drugs (NSAID’s).

On physical exam, he had psoriatic plaques on the knees, elbows, genitals and scalp. The majority of his fingernails showed pitting and onycholysis. Joint evaluation demonstrated multiple tender and swollen joints including the 2nd and 3rd metacarpal-phalangeal joints of both hands, the 2nd, 3rd and 4th distal interphalangeal joints bilaterally and both knees.

Dactylitis ("sausage digit") was present on multiple digits in both the hands and the right fourth toe along with a tender and swollen right Achilles tendon

Rheumatoid factor was negative and C reactive protein was elevated

25 mg of methotrexate given orally once weekly along with daily 1 mg of folic acid for 12 weeks failed to adequately control either the joint or skin disease.

A TNF-α inhibitor was introduced with eventual tapering of methotrexate to 10 mg once weekly.

The patient’s arthritis and skin disease dramatically improved after 4 months of this combination regimen which was maintained, allowing for significant improvement in his quality of life.

Gaps in Research

Natural History of Disease

There is a need for large prospective longitudinal broadly representative cohort studies of psoriasis.

Environmental risk factors remain poorly defined.1, 2

For identified risk factors (such as smoking, alcohol and obesity) data are necessary to determine if modification of these risk factors will prevent psoriasis or modify its severity.

The prognosis of psoriasis is poorly understood. The rate at which psoriasis will get worse over time vs. spontaneously clear as well as the determinants of alterations in psoriasis activity need to be further elucidated.

Sub-populations

The natural history and morbidity in sub-populations including children, pregnant and lactating women, the elderly, and minorities requires more study.

Little is known about disparities in treatment, health related quality of life, and other factors in sub-populations. 3-5

Co-morbidities

Psoriatic arthritis

The natural history of PsA is poorly defined in the dermatology setting. It is necessary to determine the severity of PsA and the prognosis of PsA of patients who are identified in the dermatology setting.

Data are necessary to determine if better control of psoriasis through more aggressive therapy will lead to a lower incidence of PsA.

Cardiovascular disease

The impact of objective psoriasis severity on CV risk is unknown.6-11

Studies are needed to determine how to optimize prevention of CV events in patients with psoriasis.
c. A central question is whether aggressive systemic therapy of psoriasis leads to lower CV risk.12, 13

Obesity and metabolic disease

Data are necessary to determine if achieving an ideal BMI will lower the risk of developing psoriasis and if, among those with psoriasis, if achieving a normal BMI will improve skin and joint disease.

The degree to which obesity explains the higher risk of Diabetes and metabolic syndrome observed in some studies requires additional study. 14

Mortality: Studies indicate that patients with severe psoriasis have excess mortality. The causes of death and degree to which these are altered by psoriasis itself, its treatments, or co-morbid behaviors requires further study.

Treatment

The comparative effectiveness of psoriasis treatments for plaque psoriasis is understudied. The few studies which exist are short term.15 Current data make it difficult to determine which drugs are most safe and effective long term for psoriasis and therefore should be considered the preferred treatment for most patients. As a result, most recommendations are broad and list options in “alphabetical” order.

The comparative effective of psoriasis treatments for clinical variants including guttate psoriasis, pustular psoriasis, erythrodermic psoriasis, inverse psoriasis and palmoplantar psoriasis is an area with almost no data.

Most safety data for psoriasis therapies comes from other diseases particularly rheumatoid arthritis (RA). It is unclear if such data acutely reflect the safety of TNF inhibitors, methotrexate, and other therapies in the psoriasis population.

The risks of clinically significant liver toxicity when using existing liver biopsy guidelines to treat psoriasis patients with methotrexate requires further study.

The safety and effectiveness of home or office based NB UVB in comparison to other treatments in the US population requires additional study. Studies indicate that the majority of patients with objectively severe psoriasis are treated only topically or not all. More data are necessary to determine the patient, physician, treatment, and economic factors that result in most patients with severe disease not achieving long term control of their psoriasis.

Genetics and Pathomechanisms

Studies evaluating the correlation between psoriasis genotype and phenotype should be undertaken. 16-18

The vasculature has been understudied. An animal model that over-expresses the angiopoietin receptor in keratinocytes leads to mice bearing numerous criteria of psoriasis. 5, 19